Synonym: cradle cap
Seborrhoeic dermatitis is a condition that can affect infants and cause yellow crusty greasy scaling. This is most frequently found on the scalp and, when confined to the scalp, is known as 'cradle cap'.
It also affects adults, starting around puberty. See separate Seborrhoeic Dermatitis article.
Seborrhoeic dermatitis is a papulosquamous disorder affecting the areas with most sebum, such as the scalp, face, and trunk. There is known to be an association with skin yeasts of Malassezia spp. This is thought to be due to a reaction to the yeast, rather than a simple infection. Overactivity of the sebaceous glands in the newborn may be a factor.
Seborrhoeic dermatitis is extremely common in infants. Many children with the condition are not brought to the attention of the medical services and so the precise incidence is unknown. It most commonly presents in the first six weeks, and the majority resolve over the next few weeks. Less commonly, it persists for 6-9 months or more.
Seborrhoeic dermatitis presenting in infancy is a very common condition which may be brought to the attention of the health visitor or GP.
In the majority of cases it is a benign self-limiting condition which usually clears spontaneously during the first 6-12 months of life but, in a small number, it can be particularly troublesome and require treatment.
Seborrhoeic dermatitis occurs most commonly in the lipid-rich areas of skin and, in infants, occurs predominantly on the scalp and upper face, producing an appearance which may give rise to some concern from parents. It may also occur behind the ears and in the creases of the neck, axillae and groins.
Cradle cap is very common and usually appears in the first few weeks of life. There are greasy, yellow scaling patches that may eventually coalesce to a thick, scaly layer. The condition is not usually itchy and the child is not distressed by it. There may be loss of small amounts of hair in the area of scalp affected. There may be some areas of redness around the plaques. It tends to be very scaly on the scalp, whereas in the flexural areas it may be more erythematous in nature.
- Areas of reddened skin with scales may be mistaken for atopic eczema.
- If the plaques become infected, they may resemble impetigo.
- Nappy rash or candidiasis in the groin and perianal areas (the rash of seborrhoeic dermatitis is usually sharply demarcated and brightly erythematous).
- Psoriasis may cause confusion and can look extremely similar in babies. Indeed there are some who are of the opinion that seborrhoeic dermatitis in the nappy area is in fact psoriasis..
- Fungal infections - eg, tinea.
- Irritant or contact dermatitis.
Usually no investigation is required and the diagnosis is made on clinical appearance alone.
Seborrhoeic dermatitis is uncommon in pre-adolescent children and tinea capitis is uncommon after adolescence. Dandruff in a child is more likely to represent a fungal infection. A fungal culture may aid the diagnosis but the disease may occur with a negative culture and a positive culture is not diagnostic.
Seborrhoeic dermatitis in infancy is a benign, self-limiting condition and often the most appropriate management is reassurance for the parents that the condition is not serious and will disappear on its own in good time.
Simple measures should be advised first, such as regular washing of the scalp with baby shampoo, followed by brushing with a soft brush to loosen scale. Prior to shampooing, the scales may be softened with baby oil. If necessary, crusts may be soaked overnight with white petroleum jelly or warmed vegetable/olive oil. This is then followed by shampooing in the morning. An emollient such as emulsifying ointment may also be helpful.
There is some controversy about the use of olive oil. DermNet NZ maintains that olive oil encourages growth yeasts of Malassezia spp. and should be avoided. However, a National Institute for Health and Care Excellence (NICE) evidence search in 2015 did not find sufficient evidence that olive oil should be avoidedand the NICE Clinical Knowledge Summary of 2013 continues to recommend its use as one of a number of options as above. It notes there are inadequate data in this area.
If simple measures have not been effective and treatment is needed, an imidazole cream (clotrimazole 1%, econazole 1%, or miconazole 2%) may be used twice a day. Refer to a specialist if the condition requires imidazole treatment for more than four weeks. Ketoconazole cream and shampoo have both been shown to be effective but ketoconazole is not approved for this age group in the UK[7, 8].
Do not over-treat in response to parental anxiety. Reassure parents of the benign self-limiting nature of the condition and advise on treatment where clinically needed.
Other areas of skin
- The baby should be bathed at least once a day and an emollient used as a soap substitute on the affected areas.
- Imidazole creams as above may be used once or twice a day, if required.
- Topical steroids are not usually used, other than for certain cases of nappy rash.
Consider referral if there is:
- Diagnostic uncertainty.
- Failure to respond to routine treatment.
- The need for ongoing imidazole cream treatment for more than four weeks.
- Severe or widespread seborrhoeic dermatitis.
- Eyelid involvement (where simple eyelid hygiene measures have been unsuccessful).
- Secondary infection can occur occasionally.
- Leiner's disease (severe generalised seborrhoeic dermatitis - lesions become confluent and there is widespread redness and scaling). The child becomes unwell with diarrhoea, vomiting and anaemia.
This condition usually resolves spontaneously within three to four months. In some it takes 6-9 months or longer. The majority of children with seborrhoeic dermatitis will have complete resolution and have no further skin disease. It is not known whether they have an increased risk of seborrhoeic dermatitis later in life.
Further reading and references
Cradle cap (infantile seborrhoeic dermatitis); DermNet NZ
O'Connor NR, McLaughlin MR, Ham P; Newborn skin: Part I. Common rashes. Am Fam Physician. 2008 Jan 177(1):47-52.
Seborrhoeic dermatitis; NICE CKS, February 2013 (UK access only)
Sampaio AL, Mameri AC, Vargas TJ, et al; Seborrheic dermatitis. An Bras Dermatol. 2011 Nov-Dec86(6):1061-71
Seborrhoeic eczema; Primary Care Dermatology Society (PCDS)
Olive oil treatment for cradle cap - can it worsen the condition?; UK Medicines Information (UKMi) Q and As, Updated October 2015
Hald M, Arendrup MC, Svejgaard EL, et al; Evidence-based Danish guidelines for the treatment of Malassezia-related skin diseases. Acta Derm Venereol. 2015 Jan95(1):12-9. doi: 10.2340/00015555-1825.
British National Formulary (BNF); NICE Evidence Services (UK access only)
Leiner disease; DermNet NZ
Gary G; Optimizing treatment approaches in seborrheic dermatitis. J Clin Aesthet Dermatol. 2013 Feb6(2):44-9.
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